UR - CCBHC Admission

Prescribe

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Quarter:

2nd

3rd

4th

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DOB:

Date

Date

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ID#:

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Program:

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Date of Admission:

Date

Date

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Insurance:

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SAI:

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Prescriber:

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Intake Paperwork:

	Yes	No	N/A
Jonathan's Law paperwork has been completed (self, parent, legal guardian, spouse, adult child with decision-making authority)	Jonathan's Law paperwork has been completed (self, parent, legal guardian, spouse, adult child with decision-making authority) Yes	Jonathan's Law paperwork has been completed (self, parent, legal guardian, spouse, adult child with decision-making authority) No	Jonathan's Law paperwork has been completed (self, parent, legal guardian, spouse, adult child with decision-making authority) N/A
Red Flag procedures have been followed (photo id, copy in chart in photo tab)	Red Flag procedures have been followed (photo id, copy in chart in photo tab) Yes	Red Flag procedures have been followed (photo id, copy in chart in photo tab) No	Red Flag procedures have been followed (photo id, copy in chart in photo tab) N/A
HIPAA Acknowledgement form is complete with signature	HIPAA Acknowledgement form is complete with signature Yes	HIPAA Acknowledgement form is complete with signature No	HIPAA Acknowledgement form is complete with signature N/A
Consent for treatment signed by client and/or legal guardian	Consent for treatment signed by client and/or legal guardian Yes	Consent for treatment signed by client and/or legal guardian No	Consent for treatment signed by client and/or legal guardian N/A
Releases of Information signed by client and/or legal guardian	Releases of Information signed by client and/or legal guardian Yes	Releases of Information signed by client and/or legal guardian No	Releases of Information signed by client and/or legal guardian N/A

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Admission Criteria (all that are appropriate must be met):

	Yes	No	N/A
Client has a primary diagnosis of mental illness	Client has a primary diagnosis of mental illness Yes	Client has a primary diagnosis of mental illness No	Client has a primary diagnosis of mental illness N/A
Documentation supports the Diagnosis and need for treatment	Documentation supports the Diagnosis and need for treatment Yes	Documentation supports the Diagnosis and need for treatment No	Documentation supports the Diagnosis and need for treatment N/A
SED - Non-SED Criteria (adolescents/children only)	SED - Non-SED Criteria (adolescents/children only) Yes	SED - Non-SED Criteria (adolescents/children only) No	SED - Non-SED Criteria (adolescents/children only) N/A
Follow-up with Referral Source is documented	Follow-up with Referral Source is documented Yes	Follow-up with Referral Source is documented No	Follow-up with Referral Source is documented N/A
Follow-up with PCP and other Providers is documented	Follow-up with PCP and other Providers is documented Yes	Follow-up with PCP and other Providers is documented No	Follow-up with PCP and other Providers is documented N/A

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Assessments:

	Yes	No	N/A
All relevant assessments are completed (CRAFFT, Vanderbuilt, UCLA/PTSD, MACI, Columbia Depression Scale, ECBI, SCARED) (Circle if relevant)	All relevant assessments are completed (CRAFFT, Vanderbuilt, UCLA/PTSD, MACI, Columbia Depression Scale, ECBI, SCARED) (Circle if relevant) Yes	All relevant assessments are completed (CRAFFT, Vanderbuilt, UCLA/PTSD, MACI, Columbia Depression Scale, ECBI, SCARED) (Circle if relevant) No	All relevant assessments are completed (CRAFFT, Vanderbuilt, UCLA/PTSD, MACI, Columbia Depression Scale, ECBI, SCARED) (Circle if relevant) N/A
Risk Assessment and Safety Plan completed if indicated	Risk Assessment and Safety Plan completed if indicated Yes	Risk Assessment and Safety Plan completed if indicated No	Risk Assessment and Safety Plan completed if indicated N/A
The mental health diagnosis matches the psychiatrist's diagnosis	The mental health diagnosis matches the psychiatrist's diagnosis Yes	The mental health diagnosis matches the psychiatrist's diagnosis No	The mental health diagnosis matches the psychiatrist's diagnosis N/A
Health Review has been completed and signed before Treatment Plan	Health Review has been completed and signed before Treatment Plan Yes	Health Review has been completed and signed before Treatment Plan No	Health Review has been completed and signed before Treatment Plan N/A
Assessments describe necessity for services in language other than English, when appropriate	Assessments describe necessity for services in language other than English, when appropriate Yes	Assessments describe necessity for services in language other than English, when appropriate No	Assessments describe necessity for services in language other than English, when appropriate N/A
Substance Abuse was adequately assessed; Positive NIDA Quick Screen=Positive NIDA Expanded Screen (2 years SA recovery considered early recovery)	Substance Abuse was adequately assessed; Positive NIDA Quick Screen=Positive NIDA Expanded Screen (2 years SA recovery considered early recovery) Yes	Substance Abuse was adequately assessed; Positive NIDA Quick Screen=Positive NIDA Expanded Screen (2 years SA recovery considered early recovery) No	Substance Abuse was adequately assessed; Positive NIDA Quick Screen=Positive NIDA Expanded Screen (2 years SA recovery considered early recovery) N/A

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Treatment plan:

	Yes	No	N/A
The Treatment Plan is compatible with client's diagnosis	The Treatment Plan is compatible with client's diagnosis Yes	The Treatment Plan is compatible with client's diagnosis No	The Treatment Plan is compatible with client's diagnosis N/A
The Treatment Plan has been completed and signed by the Dr. within 30 days of admission date	The Treatment Plan has been completed and signed by the Dr. within 30 days of admission date Yes	The Treatment Plan has been completed and signed by the Dr. within 30 days of admission date No	The Treatment Plan has been completed and signed by the Dr. within 30 days of admission date N/A
The objectives address the areas of need identified by the client	The objectives address the areas of need identified by the client Yes	The objectives address the areas of need identified by the client No	The objectives address the areas of need identified by the client N/A
Treatment objectives are written in behavioral and measurable terms; number is realistic (2-5)	Treatment objectives are written in behavioral and measurable terms; number is realistic (2-5) Yes	Treatment objectives are written in behavioral and measurable terms; number is realistic (2-5) No	Treatment objectives are written in behavioral and measurable terms; number is realistic (2-5) N/A
Client strengths are identified	Client strengths are identified Yes	Client strengths are identified No	Client strengths are identified N/A
If medications are prescribed, medication therapy is listed as an objective	If medications are prescribed, medication therapy is listed as an objective Yes	If medications are prescribed, medication therapy is listed as an objective No	If medications are prescribed, medication therapy is listed as an objective N/A
The Treatment Plan describes a level of care consistent with the assessments	The Treatment Plan describes a level of care consistent with the assessments Yes	The Treatment Plan describes a level of care consistent with the assessments No	The Treatment Plan describes a level of care consistent with the assessments N/A
Discharge criteria are behaviorally defined and measurable	Discharge criteria are behaviorally defined and measurable Yes	Discharge criteria are behaviorally defined and measurable No	Discharge criteria are behaviorally defined and measurable N/A
All services being delivered are listed on the treatment plan and frequency is appropriate	All services being delivered are listed on the treatment plan and frequency is appropriate Yes	All services being delivered are listed on the treatment plan and frequency is appropriate No	All services being delivered are listed on the treatment plan and frequency is appropriate N/A
Appropriate linkages/communications with other providers is documented	Appropriate linkages/communications with other providers is documented Yes	Appropriate linkages/communications with other providers is documented No	Appropriate linkages/communications with other providers is documented N/A
Client/Guardian signed the Treatment Plan	Client/Guardian signed the Treatment Plan Yes	Client/Guardian signed the Treatment Plan No	Client/Guardian signed the Treatment Plan N/A
Treatment Plan is consistent with level of care that is being provided	Treatment Plan is consistent with level of care that is being provided Yes	Treatment Plan is consistent with level of care that is being provided No	Treatment Plan is consistent with level of care that is being provided N/A
Treatment Plans must include physical health, behavioral health, social service needs and SUD if needed	Treatment Plans must include physical health, behavioral health, social service needs and SUD if needed Yes	Treatment Plans must include physical health, behavioral health, social service needs and SUD if needed No	Treatment Plans must include physical health, behavioral health, social service needs and SUD if needed N/A
All diagnoses for which a patient is being treated should be included in the plan with specific treatment goals to address each area of identified patient diagnoses	All diagnoses for which a patient is being treated should be included in the plan with specific treatment goals to address each area of identified patient diagnoses Yes	All diagnoses for which a patient is being treated should be included in the plan with specific treatment goals to address each area of identified patient diagnoses No	All diagnoses for which a patient is being treated should be included in the plan with specific treatment goals to address each area of identified patient diagnoses N/A
Nicotine abuse is addressed on the Treatment Plan if there is a diagnosis (CD Only)	Nicotine abuse is addressed on the Treatment Plan if there is a diagnosis (CD Only) Yes	Nicotine abuse is addressed on the Treatment Plan if there is a diagnosis (CD Only) No	Nicotine abuse is addressed on the Treatment Plan if there is a diagnosis (CD Only) N/A

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Progress Notes:

	Yes	No	N/A
Notes identify who was seen (formal names) and the duration of time	Notes identify who was seen (formal names) and the duration of time Yes	Notes identify who was seen (formal names) and the duration of time No	Notes identify who was seen (formal names) and the duration of time N/A
Notes are relevant, reflect treatment objective, progress towards goals and provide rationale for continued treatment	Notes are relevant, reflect treatment objective, progress towards goals and provide rationale for continued treatment Yes	Notes are relevant, reflect treatment objective, progress towards goals and provide rationale for continued treatment No	Notes are relevant, reflect treatment objective, progress towards goals and provide rationale for continued treatment N/A
Notes reflect Evidence-based treatment being utilized	Notes reflect Evidence-based treatment being utilized Yes	Notes reflect Evidence-based treatment being utilized No	Notes reflect Evidence-based treatment being utilized N/A
Lethality Issues are clearly addressed and documented and reflect change in risk status, follow-up/crisis and related services	Lethality Issues are clearly addressed and documented and reflect change in risk status, follow-up/crisis and related services Yes	Lethality Issues are clearly addressed and documented and reflect change in risk status, follow-up/crisis and related services No	Lethality Issues are clearly addressed and documented and reflect change in risk status, follow-up/crisis and related services N/A
Services are delivered in language specified on Treatment Plan	Services are delivered in language specified on Treatment Plan Yes	Services are delivered in language specified on Treatment Plan No	Services are delivered in language specified on Treatment Plan N/A
Group Notes are relevant and address treatment goals and objectives	Group Notes are relevant and address treatment goals and objectives Yes	Group Notes are relevant and address treatment goals and objectives No	Group Notes are relevant and address treatment goals and objectives N/A

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Date last seen

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Medication Monitoring:

	Yes	No	N/A
Psychiatric Assessment and MSE congruent with diagnosis	Psychiatric Assessment and MSE congruent with diagnosis Yes	Psychiatric Assessment and MSE congruent with diagnosis No	Psychiatric Assessment and MSE congruent with diagnosis N/A
Cardio Metabolic Risk monitoring begun (Med. Cond: Ht & Wt sufficient)	Cardio Metabolic Risk monitoring begun (Med. Cond: Ht & Wt sufficient) Yes	Cardio Metabolic Risk monitoring begun (Med. Cond: Ht & Wt sufficient) No	Cardio Metabolic Risk monitoring begun (Med. Cond: Ht & Wt sufficient) N/A
Notes document crises and related services	Notes document crises and related services Yes	Notes document crises and related services No	Notes document crises and related services N/A
Medication notes and e-prescribe/Medication sheets coincide	Medication notes and e-prescribe/Medication sheets coincide Yes	Medication notes and e-prescribe/Medication sheets coincide No	Medication notes and e-prescribe/Medication sheets coincide N/A
An AIMS is done on clients receiving neuroleptic medications (annually, all antipsychotics)	An AIMS is done on clients receiving neuroleptic medications (annually, all antipsychotics) Yes	An AIMS is done on clients receiving neuroleptic medications (annually, all antipsychotics) No	An AIMS is done on clients receiving neuroleptic medications (annually, all antipsychotics) N/A
I-Stop has been checked	I-Stop has been checked Yes	I-Stop has been checked No	I-Stop has been checked N/A

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Date last seen

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Other:

	Yes	No	N/A
Records from past providers (inpatient/outpatient) requested	Records from past providers (inpatient/outpatient) requested Yes	Records from past providers (inpatient/outpatient) requested No	Records from past providers (inpatient/outpatient) requested N/A
Frequency of contact is appropriate to client/family treatment needs	Frequency of contact is appropriate to client/family treatment needs Yes	Frequency of contact is appropriate to client/family treatment needs No	Frequency of contact is appropriate to client/family treatment needs N/A
Program Director has completed Admission UR	Program Director has completed Admission UR Yes	Program Director has completed Admission UR No	Program Director has completed Admission UR N/A

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Comments: